Individual
TORY KIRSTEN ETHERIDGE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
NP
Contact information
Practice address
4120 GRAY HWY, GRAY, GA 31032-6156
(478) 320-2298
Mailing address
4120 GRAY HWY, GRAY, GA 31032-6156
(478) 320-2298
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
2017026648
GA
363LA2100X
Acute Care Nurse Practitioner
2017026648
GA
363LG0600X
Gerontology Nurse Practitioner
2017026648
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
RN223023
GA LICENSE
—
Enumeration date
02/21/2018
Last updated
10/09/2024
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